FOREIGN BODY

AIRWAY
OBSTRUCTION IN
CHILDREN
Arnol D. Magbanua, RN, MAN
 INTRODUCTION

Between 2014 and 2016 there were 30 deaths from choking in

infants and children aged <14 years in England and Wales (Office
for National Statistics, 2017). The causes of foreign-body airway
obstruction (FBAO) are split equally between food and small
objects

A quick response can prevent death from choking, so nurses

should be able to recognise and respond to FBAO. Those working
with families should also ensure parents know how to prevent,
recognise and respond to it.
 CHOKING

Choking is a life-threatening
emergency that nurses must be
able to recognise and treat
 FBAO

Is clinical emergency that may be life

threatening. Nurses should be confident in
assessing the severity of airway obstruction,
delivering interventions to relieve the airway
obstruction and knowing when to call for
assistance.
 SIGNS OF FBAO

Recognising the signs of FBAO in infants

and children is the key to early, effective
intervention. The context may provide
important clues – for example, choking is
common at mealtimes, or a child may
have been playing with small objects that
easily fit into the mouth. The most
common signs and symptoms of choking
are:
 SIGNS OF FBAO

A cough;
Struggling to breathe or talk (cry in infants);
Gagging – the infant/child may go silent and
hold or point to their throat.
If the obstruction is only partial, the child may
be able to vocalise/cry, cough and breathe
 CAUSES OF FBAO

Other causes of airway obstruction in children – including

laryngitis and epiglottitis – present with similar symptoms.
The presence of a foreign body should be suspected if the
symptoms have a sudden onset and there are no other systemic
signs of illness such as pyrexia.. If FBAO is suspected, it is
important to assess the severity by establishing whether the
infant/child has an effective or ineffective cough. In older
children it is useful to ask “are you choking?”; their response
will help distinguish between a mild or severe obstructive
airway
 CAUSES OF FBAO

• Altered level of consciousness

• Drug and/or alcohol intoxication
• Neurological impairment, with reduced swallowing and cough
reflexes (for example, stroke)
• Respiratory disease
• Mental impairment
• Dementia
• Poor dentition
• Geriatrics
• Use of Metered Dose Inhalers
 SIGNS OF FBAO

Recognising the signs of FBAO is the

key to early and effective
intervention. The context may
provide important clues – for
example, choking is common at
mealtimes or a child may have been
playing with small objects.
 SIGNS OF FBAO

• A cough
• Struggling to breathe or talk
• Cyanosis
• Grasping or reaching for the throat.
• The patient may go silent and hold or
point to their throat (Universal Sign of
Choking).
 ASSESSMENT OF FBAO

If FBAO is suspected, it is
important to assess its severity
and always ask the patient
“are you choking?”. Their
response will help distinguish
between a mild or severe
obstructive airway
 SEVERIT Y OF AIRWAY
OBS TRUCTION
Mild obstruction (effective cough)

The infant/child:

Is crying/able to verbally respond to questions

Has a loud cough

Is able to take a breath before coughing and is fully

responsive
 SEVERIT Y OF AIRWAY
OBS TRUCTION
Severe obstruction (ineffective cough)
Typically the infant/child:
Is unable to vocalise
Is quiet
Has a silent cough
Is unable to breathe
Shows signs of cyanosis and decreasing levels of
consciousness
 SEVERITY OF AIRWAY OBSTRUCTION

• Mild airway obstruction (effective

cough): patient able to talk and has an
effective cough
• Severe airway obstruction
(ineffective cough): typically, patient
responds “yes” by nodding their head
without speaking; unable to cough
effectively
BACK SLAPS IN INFANT S
 PREVENTION OF
CHOKING IN INFANTS
AND CHILDREN
Nurses should advise parents to:

Always cut up food: infants and young children can

choke on small, sticky or slippery foods

Keep small objects out of reach: infants and small

children examine objects by putting them in their
mouths. Ensure small toys/objects such as building
bricks, button batteries, coins and marbles are stored
out of reach

Sit children down to eat

Always supervise infants and young children

 MILD AIRWAY OBSTRUCTION

Coughing generates high and sustained airway pressures

and may expel a foreign body, so it is important to
encourage the patient to cough. A patient with mild
airway obstruction should remain under continuous
observation until they improve as a severe obstruction
may subsequently develop.

Aggressive treatment with back blows and chest and

abdominal thrusts at this stage is unnecessary – it may
cause harm and could exacerbate the airway
obstruction. These interventions should only be used if
the patient shows signs of severe airway obstruction
 MILD AIRWAY OBSTRUCTION (EFFECTIVE
COUFH)

Coughing generates high and sustained airway

pressures, and may expel a foreign body, so it is
important to encourage the child to cough. Children
with an effective cough will be able to cry or verbally
respond to questions. In these situations, no external
manoeuvres – such as back blows – are needed but
close observation is required until the infant/child
improves, as severe airway obstruction may develop.
 SEVERE AIRWAY OBSTRUCTION

Ineffective Cough (Infants Less than 1 year)

If the patient shows signs of severe airway

obstruction:

• Call for help/pull the emergency buzzer

immediately and encourage the patient to
cough;
Deliver up to five back blows (slaps) using
the following procedure:
 SEVERE AIRWAY OBSTRUCTION

Place the infant in a prone position (usually over the lap) with
the head downwards to enable gravity to help remove the
foreign body;

Stabilise the infant’s (floppy) head: place the thumb of one

hand at the angle of the lower jaw and one or two fingers on
the opposite side of the jaw (take care not to compress the soft
tissues under the infant’s jaw, as this could exacerbate the
obstruction of the airway);

Deliver up to five sharp back blows (slaps) with the heel of

one hand in the middle of the back between the shoulder
blades. Following each back blow, check to see whether it has
relieved the obstruction.
BACK SLAPS IN INFANT S
 SEVERE AIRWAY OBSTRUCTION (CONT)

If back blows fail to dislodge

the object and the infant is still
conscious, deliver up to five
chest thrusts
 SEVERE AIRWAY OBSTRUCTION (CONT)

Turn the infant supine with head in a downwards position,

using your arm to support the infant’s back and your hand
to support the head. Your thigh can provide additional
support;
Locate the ‘landmark’ for chest compressions – this is the
lower sternum approximately a finger-width above the
xiphisternum;
Perform up to five chest thrusts – these are like chest
compressions, but sharper in nature and delivered at a
slower rate;
Following each chest thrust, check to see whether the
obstruction has been dislodged;
If the obstruction remains, continue alternating up to five
back blows with up to five chest thrusts.
 S E V E R E A I R WA Y
O B S T RU C T I O N ( I N E F F E C T I V E
COUGH) IN CHILDREN (>1 YEAR)

If a child shows signs of severe airway obstruction:

Call for help/pull the emergency buzzer immediately

if in the hospital;
Deliver up to five back blows (slaps) Figure 4
 S E V E R E A I R WA Y
O B S T RU C T I O N ( I N E F F E C T I V E
COUGH) IN CHILDREN (>1 YEAR)

Deliver up to five sharp back blows (slaps) with the

heel of one hand in the middle of the back between
the shoulder blades (Fig 4). Following each back blow,
check to see whether the obstruction has been
dislodged.
 S E V E R E A I R WA Y
O B S T RU C T I O N ( I N E F F E C T I V E
COUGH) IN CHILDREN (>1 YEAR)

Position the child with their head down

(a small child may be placed over the
lap, as described above). If this is not
feasible, support the child into the
leaning-forward position recommended
for adults (Fig 5);
 S E V E R E A I R WA Y
O B S T RU C T I O N ( I N E F F E C T I V E
COUGH) IN CHILDREN (>1 YEAR)

Position the child with their head down

(a small child may be placed over the
lap, as described above). If this is not
feasible, support the child into the
leaning-forward position recommended
for adults (Fig 5);
 S E V E R E A I R WA Y
O B S T RU C T I O N ( I N E F F E C T I V E
COUGH) IN CHILDREN (>1 YEAR)

If back blows fail to dislodge the

object and the child is still
conscious, deliver up to five
abdominal thrusts (Fig 5) using the
following procedure:
 S E V E R E A I R WA Y
O B S T RU C T I O N ( I N E F F E C T I V E
COUGH) IN CHILDREN (>1 YEAR)
Position yourself behind the child either standing or kneeling. Place your
arms under the child’s arms;

Place a clenched fist between the umbilicus and xiphisternum;

Hold the clenched fist with your other hand; pull sharply inwards and
upwards;

Deliver up to five abdominal thrusts. Following each abdominal thrust,

check to see whether the obstruction has been dislodged;

Take care not to apply pressure to the xiphoid process or the lower rib
cage as this may cause abdominal trauma;

If the obstruction remains, continue alternating up to five back blows

with up to five abdominal thrusts.
 IF THE PATIENT LOSES CONSCIOUSNESS YOU
SHOULD:

Carefully support them to a flat surface;

Summon help if it is still not available (do not

leave the infant/child);

Open the infant’s/child’s mouth. If an obvious

object is seen, attempt to remove it with a single
finger sweep. Blind or repeated finger sweeps are
not recommended because the object could be
pushed deeper into the pharynx;
 IF THE PATIENT LOSES CONSCIOUSNESS YOU
SHOULD:

Open the airway and attempt five ventilations.

Determine the effectiveness of each ventilation – if
the chest fails to rise, reposition the head;

If the infant/child remains unresponsive, commence chest

compressions immediately. It is advised for a lone rescuer
to perform cardiopulmonary resuscitation for one minute
before summoning assistance;

Before repeating ventilations, check the mouth for the

presence of an object and remove it if this is possible (see
above) (Maconochie et al, 2017).
 AFTERCARE AND REFERRAL

After successful treatment for a FBAO, the foreign body

may still be present in the airways and can cause
complications. Advise parents/carers that they should seek
medical advice if the infant/child has dysphagia or a
persistent cough, or complains of having something stuck in
their throat.

As chest/abdominal thrusts and chest compressions can

cause serious internal injury, patients must be examined for
injuries after these interventions have been performed
(Perkins et al, 2017).
 CONCLUSION

Professional responsibilities – These

procedures should be undertaken only
after approved training, supervised
practice and competency assessment, and
carried out in accordance with local
policies and protocols.